A 69-year-old woman, gravida 5 para 5, comes to the office for leakage of urine. The patient reports that her urine "leaks all the time" and that she is "afraid to leave the house because I constantly smell like urine." She is also "exhausted from waking up every hour to go to the bathroom." Since menopause at age 53, the patient has had occasional leakage of urine after sneezing, but her symptoms have worsened over the last few months. She has type 2 diabetes mellitus and is on an insulin regimen. The patient recently moved to be closer to her grandchildren; since moving, she has been diagnosed with allergic rhinitis and started on a daily antihistamine. She has had no previous surgery. The patient's pregnancies all resulted in spontaneous vaginal deliveries; the largest infant was 4.6 kg (10.2 lb). She does not use tobacco, alcohol, or illicit drugs. The patient does aqua-aerobic exercises at the senior center 5 times a week. Blood pressure is 120/80 mm Hg and pulse is 70/min. BMI is 25 kg/m². Abdominal examination shows no tenderness or masses. Speculum examination shows a pale vagina but no evidence of pelvic organ prolapse. Bimanual examination shows a small, mobile, nontender uterus and no adnexal masses. Urine dribbling is noted on examination, but no leakage occurs when the patient is asked to cough. There is decreased sensation to pinprick testing over the perineum. Which of the following is the most likely diagnosis in this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_c149_00b2_8f63_b7af8976dd3f_MD0005_00 Overflow incontinence occurs due to incomplete bladder emptying that is the result of decreased detrusor muscle contractility and/or bladder outlet obstruction. Urine accumulates, distends the bladder, and increases the intravesicular pressure. Whenever the intravesicular pressure is greater than the urethral closing pressure, urine dribbles out. Therefore, patients with overflow incontinence commonly experience constant urinary leakage, nocturia, and a weak urinary stream. Typical examination findings include decreased perineal sensation (eg, neuropathy) and a large post-void residual urine volume (>150 mL). Overflow incontinence is often associated with neuropathy (eg, poorly controlled diabetes mellitus, spinal injury, multiple sclerosis). Patients with an underlying neuropathy can develop overflow incontinence when additional risk factors (eg, antihistamines) result in exacerbation of symptoms (as in this patient). Treatment includes correction of any underlying etiology and intermittent self-catheterization. (Choice A) Genitourinary syndrome of menopause can cause urinary symptoms due to vulvovaginal atrophy; however, it typically presents with an associated dyspareunia, vulvar irritation, and pelvic organ prolapse, which are not seen in this patient. (Choices B and D) Intrinsic sphincter deficiency and urethral hypermobility are associated with stress urinary incontinence - involuntary leakage of urine that occurs with increased intraabdominal pressure (eg, coughing, sneezing, Valsalva). Patients with stress urinary incontinence typically have a positive bladder stress test (leakage of urine with coughing during examination), which is not seen in this patient. (Choice E) Urgency incontinence (also known as overactive bladder) typically presents with a sudden, overwhelming urge to void followed by an involuntary loss of urine. Educational objective: Overflow incontinence presents as a constant dribbling of urine and is due to bladder distension from incomplete emptying. Typical examination findings include signs of neuropathy and an increased post-void residual urine volume (>150 mL). Treatment involves intermittent self-catheterization and correction of the underlying etiology. References: Diagnosis of urinary incontinence. (http://www.ncbi.nlm.nih.gov/pubmed/23668444)

A 69-Year-Old Woman, Gravida 5 Para 5, Comes to the Office